Sarah Michelle Live Review - FNP & AGNP Board Preparation 250 Questions - AGRADE Verified 2026/2027
Sarah Michelle Live Review (Complete)
FNP & AGNP Board Certification Examination Preparation — 250 Questions with Verified Answers and
Clinical Pearls
2026/2027 Edition | Real Exam-Aligned Content, Clinical Pearls & Tested Concepts | AGRADE
Verified
Aligned with current FNP and AGNP certification exam blueprint (AANP, ANCC, AAENP) and Sarah Michelle Live Review tested concepts
Instructions to Candidate: This examination consists of 250 multiple-choice items distributed across ten content domains covering
the full FNP/AGNP board certification blueprint. Each item has exactly one best answer. Cognitive level distribution: approximately
25% recall (clinical guidelines, pharmacology), 50% application (clinical scenarios requiring diagnostic reasoning and management
decisions), and 25% analysis (integration of multiple findings, differential diagnosis, 'next best step' clinical reasoning). The correct
answer and a rationale with embedded clinical pearls and high-yield test-taking strategies are provided immediately beneath each
item to support self-assessment, remediation, and board-focused study.
Section 1: Cardiovascular Disorders (Q1-Q30)
Hypertension, Heart Failure, CAD, Dysrhythmias, & Lipid Management
Q1: A 58-year-old African American male presents for routine physical examination. His blood pressure today is
148/94 mmHg, confirmed on two readings. He has no history of cardiovascular disease or diabetes. According to
the 2017 ACC/AHA hypertension guideline, what is the appropriate classification and initial management?
A. Stage 1 hypertension; recommend lifestyle modification and recheck in 6 months
B. Stage 2 hypertension; recommend lifestyle modification PLUS antihypertensive medication with two agents
from different classes, with follow-up in 1 month [CORRECT]
C. Elevated blood pressure; recommend lifestyle modification only
D. Hypertensive crisis; refer immediately to the emergency department
Correct Answer: B
Rationale:
Per the 2017 ACC/AHA guideline, BP >=140/90 mmHg is Stage 2 hypertension, requiring both lifestyle modification and
pharmacologic therapy with TWO agents from different classes (typically thiazide + ACE/ARB/CCB for African American
patients). Clinical pearl: African American patients have a more robust BP response to thiazides and CCBs than to ACE inhibitors
monotherapy. Lifestyle modifications (DASH diet, sodium <1500 mg/day, exercise, weight loss, alcohol moderation) are
foundational at all stages.
Q2: A 62-year-old white female with stage 2 hypertension and a history of heart failure with reduced ejection
fraction (HFrEF, EF 30%) is started on antihypertensive therapy. Which of the following is the MOST
appropriate first-line antihypertensive agent?
A. Amlodipine 10 mg daily
B. Lisinopril 10 mg daily (ACE inhibitor with mortality benefit in HFrEF) [CORRECT]
C. Hydrochlorothiazide 25 mg daily
D. Clonidine 0.1 mg BID
Correct Answer: B
Rationale:
For patients with HFrEF, an ACE inhibitor (or ARB if ACE cough/angioedema) provides mortality benefit by reducing afterload
and counteracting maladaptive remodeling. ACE inhibitors are foundational in HFrEF alongside beta-blockers, MRAs, and SGLT2
Page 1 | Advanced Practice Nursing Board Review
,Sarah Michelle Live Review - FNP & AGNP Board Preparation 250 Questions - AGRADE Verified 2026/2027
inhibitors (GDMT). Clinical pearl: CCBs (non-dihydropyridines like diltiazem/verapamil) are CONTRAINDICATED in HFrEF
because they reduce contractility; amlodipine is generally neutral but not first-line. Clonidine is not first-line for chronic HTN.
Q3: A 76-year-old patient with hypertension, type 2 diabetes, and stage 3 CKD (eGFR 35 mL/min) is being
managed for elevated BP. The FNP recognizes that the preferred agent for renal protection in this patient is:
A. Hydrochlorothiazide 25 mg daily
B. Losartan 50 mg daily (ARB, with evidence of renal protection in CKD with albuminuria) [CORRECT]
C. Amlodipine 10 mg daily
D. Metoprolol succinate 50 mg daily
Correct Answer: B
Rationale:
ACE inhibitors and ARBs are preferred in patients with diabetes and CKD with albuminuria (UACR >=30 mg/g) because they
reduce intraglomerular pressure and slow progression of diabetic nephropathy. Monitor creatinine (may rise up to 30% acceptable)
and potassium. Clinical pearl: Thiazides lose efficacy at eGFR <30 (use loop diuretic); metoprolol does not provide renal protection.
Avoid aliskiren (renin inhibitor) combined with ACE/ARB in diabetics due to hyperkalemia and renal dysfunction risk.
Q4: A 28-year-old G2P1 at 24 weeks gestation presents with blood pressure 158/102 mmHg on two readings,
with 1+ proteinuria on dipstick. She has a frontal headache and blurred vision. The FNP recognizes the MOST
appropriate diagnosis and immediate action:
A. Chronic hypertension; continue prenatal care and recheck in 2 weeks
B. Preeclampsia with severe features (hypertension PLUS neurologic symptoms and proteinuria); requires
emergent obstetric evaluation, magnesium sulfate for seizure prophylaxis, and antihypertensive therapy (IV
labetalol or hydralazine) [CORRECT]
C. Gestational hypertension; outpatient monitoring only
D. Eclampsia; administer IV diazepam
Correct Answer: B
Rationale:
Preeclampsia with severe features is diagnosed with BP >=160 systolic or >=110 diastolic PLUS end-organ damage (neurologic
symptoms, proteinuria, elevated LFTs, thrombocytopenia, pulmonary edema, fetal growth restriction). Treatment: IV magnesium
sulfate for seizure prophylaxis, IV labetalol or hydralazine for BP control, and delivery if >=34 weeks. Clinical pearl: Eclampsia is
when seizures actually occur. Do NOT delay for further workup when severe features present.
Q5: A 65-year-old male with hypertension, type 2 diabetes, and Stage 3 CKD is on maximal doses of lisinopril
and amlodipine. His BP remains 152/94 mmHg. The FNP adds chlorthalidone 25 mg daily. Three weeks later,
the patient presents with severe muscle cramps and weakness. ECG shows peaked T waves and wide QRS. The
MOST likely diagnosis is:
A. Hypokalemia from thiazide diuretic
B. Hyperkalemia from RAAS blockade combined with CKD, exacerbated by additional renal hemodynamic
changes [CORRECT]
C. Hyponatremia
D. Hypomagnesemia
Correct Answer: B
Rationale:
Adding a thiazide to ACE inhibitor + CKD raises hyperkalemia risk (uncommon for thiazides alone, but the combination with ACE
+ CKD + diabetes is a high-risk scenario). ECG findings of peaked T waves and wide QRS are classic for hyperkalemia. Clinical
pearl: ALWAYS check BMP within 1-2 weeks of starting/adjusting ACE/ARB, especially in CKD and diabetes. Hypokalemia
would cause U waves, flat T waves, and ST depression. Treatment: calcium gluconate, insulin+glucose, albuterol, then definitive
Page 2 | Advanced Practice Nursing Board Review
,Sarah Michelle Live Review - FNP & AGNP Board Preparation 250 Questions - AGRADE Verified 2026/2027
removal (diuretics, GI resins, dialysis).
Q6: A 72-year-old female presents with BP 188/110 mmHg, severe headache, and confusion. Funduscopic exam
reveals papilledema. The FNP correctly identifies this as hypertensive emergency. The MOST appropriate
immediate intervention is:
A. Sublingual nifedipine 10 mg for rapid BP reduction
B. IV labetalol or nicardipine with continuous arterial line monitoring, reducing mean arterial pressure by no
more than 25% in the first hour [CORRECT]
C. Oral clonidine 0.2 mg, repeated as needed
D. Oral hydrochlorothiazide 25 mg
Correct Answer: B
Rationale:
Hypertensive emergency requires ICU admission and IV titratable antihypertensive (labetalol, nicardipine, clevidipine, esmolol).
Lower MAP by NO more than 25% in the first hour to prevent cerebral hypoperfusion (chronic HTN shifts cerebral autoregulation
curve). Clinical pearl: NEVER use sublingual nifedipine - rapid, unpredictable BP reduction can precipitate stroke, MI, or death.
Oral agents (clonidine, captopril) are for hypertensive urgency (no end-organ damage).
Q7: A 68-year-old male with HFrEF (EF 25%) presents with dyspnea on exertion, orthopnea, and 2+ bilateral
lower extremity edema. He is currently on furosemide 40 mg daily. Which FOUR medications constitute
Guideline-Directed Medical Therapy (GDMT) for HFrEF?
A. Furosemide, hydralazine, isosorbide dinitrate, and digoxin
B. ARNI (or ACE/ARB if intolerant), evidence-based beta-blocker (carvedilol/metoprolol succinate/bisoprolol),
mineralocorticoid receptor antagonist (spironolactone/ eplerenone), and SGLT2 inhibitor
(dapagliflozin/empagliflozin) [CORRECT]
C. ACE inhibitor, loop diuretic, digoxin, and statin
D. Beta-blocker, CCB, statin, and nitrate
Correct Answer: B
Rationale:
The FOUR pillars of GDMT for HFrEF are: (1) ARNI (sacubitril/valsartan) preferred over ACE/ARB; (2) evidence-based
beta-blocker (carvedilol, metoprolol succinate, bisoprolol - NOT metoprolol tartrate); (3) MRA (spironolactone or eplerenone); (4)
SGLT2 inhibitor (dapagliflozin or empagliflozin). Clinical pearl: ARNI cannot be given within 36 hours of ACE due to angioedema
risk. African American patients with NYHA III-IV HF benefit from hydralazine + isosorbide dinitrate addition. Diuretics are
symptom-relief only, not mortality-reducing.
Q8: A 70-year-old female is diagnosed with HFpEF (EF 55%) after an echocardiogram. She has hypertension,
type 2 diabetes, and chronic kidney disease. Which therapy has been shown to reduce HF hospitalizations in
HFpEF?
A. Carvedilol 12.5 mg BID
B. Empagliflozin 10 mg daily (SGLT2 inhibitor - approved for HFpEF based on EMPEROR-Preserved
trial) [CORRECT]
C. Lisinopril 20 mg daily
D. Spironolactone 25 mg daily
Correct Answer: B
Rationale:
SGLT2 inhibitors (empagliflozin, dapagliflozin) are the FIRST class to show benefit in HFpEF, reducing HF hospitalizations
(EMPEROR-Preserved, DELIVER trials). Diuretics provide symptom relief. Clinical pearl: Spironolactone (TOPCAT trial) showed
benefit in selected HFpEF patients but is more controversial. Beta-blockers, ACE/ARB, and ARNI do NOT improve outcomes in
Page 3 | Advanced Practice Nursing Board Review
, Sarah Michelle Live Review - FNP & AGNP Board Preparation 250 Questions - AGRADE Verified 2026/2027
HFpEF as they do in HFrEF. Management focuses on BP control, volume management, and treating comorbidities.
Q9: A 65-year-old male with HFrEF on GDMT (lisinopril, carvedilol, spironolactone, dapagliflozin) reports dry
cough for 3 months, worse at night. The FNP suspects ACE inhibitor-induced cough. The MOST appropriate
intervention is:
A. Discontinue carvedilol
B. Switch lisinopril to valsartan/sacubitril (ARNI), which has lower cough/angioedema risk and added mortality
benefit in HFrEF [CORRECT]
C. Addition of oral pseudoephedrine for symptomatic relief
D. Discontinue spironolactone
Correct Answer: B
Rationale:
ACE inhibitor cough occurs in 5-20% of patients due to accumulation of bradykinin (ACE normally degrades bradykinin). Switch to
ARB or ARNI - both avoid bradykinin pathway. ARNI (sacubitril/valsartan) is preferred in HFrEF due to mortality benefit
(PARADIGM-HF). Clinical pearl: ARNI must NOT be started within 36 hours of last ACE dose due to angioedema risk.
Spironolactone and carvedilol are not cough causes. Do NOT add decongestants.
Q10: A 70-year-old male on spironolactone 50 mg daily for HFrEF reports bilateral breast enlargement and
tenderness. Laboratory studies are otherwise normal. The MOST appropriate intervention is:
A. Discontinue spironolactone entirely
B. Switch to eplerenone 50 mg daily (selective MRA with lower anti-androgen effects, less
gynecomastia) [CORRECT]
C. Reduce the dose to 12.5 mg daily
D. Addition of tamoxifen
Correct Answer: B
Rationale:
Spironolactone binds androgen and progesterone receptors, causing gynecomastia (~10%), sexual dysfunction, and menstrual
irregularities. Eplerenone is a selective MRA with 100-fold lower affinity for androgen receptors, dramatically reducing
gynecomastia risk. Clinical pearl: Eplerenone has the same mortality benefit as spironolactone in HFrEF (EPHESUS,
EMPHASIS-HF). Don't discontinue MRA in HFrEF - it provides mortality benefit. Monitor K+ with both agents.
Q11: A 55-year-old male with type 2 diabetes, hypertension, and dyslipidemia presents for routine follow-up.
ASCVD 10-year risk is calculated at 12%. His lipid panel shows LDL 145 mg/dL, HDL 38 mg/dL, TG 200
mg/dL. The FNP correctly identifies the appropriate management per 2018 ACC/AHA cholesterol guidelines:
A. Continue lifestyle modifications; no statin indicated
B. Initiate moderate-intensity statin therapy (e.g., atorvastatin 10-20 mg or rosuvastatin 5-10 mg
daily) [CORRECT]
C. Initiate high-intensity statin therapy (e.g., rosuvastatin 20-40 mg daily)
D. Addition of ezetimibe first, then statin
Correct Answer: B
Rationale:
For primary prevention in adults 40-75 years with LDL 70-189 mg/dL and 10-year ASCVD risk >=7.5%, initiate moderate-intensity
statin. Diabetes is an automatic statin indication; moderate-intensity for diabetics 40-75 years at <7.5% risk, high-intensity at
>=7.5%. Clinical pearl: Discuss risk-enhancing factors (family history, CKD, metabolic syndrome, triglycerides >175, hs-CRP >2,
LP(a) >125 nmol/L, ABI <0.9) for borderline risk (5-7.5%) decisions. Lifestyle first but never as monotherapy when statin indicated.
Page 4 | Advanced Practice Nursing Board Review
Sarah Michelle Live Review (Complete)
FNP & AGNP Board Certification Examination Preparation — 250 Questions with Verified Answers and
Clinical Pearls
2026/2027 Edition | Real Exam-Aligned Content, Clinical Pearls & Tested Concepts | AGRADE
Verified
Aligned with current FNP and AGNP certification exam blueprint (AANP, ANCC, AAENP) and Sarah Michelle Live Review tested concepts
Instructions to Candidate: This examination consists of 250 multiple-choice items distributed across ten content domains covering
the full FNP/AGNP board certification blueprint. Each item has exactly one best answer. Cognitive level distribution: approximately
25% recall (clinical guidelines, pharmacology), 50% application (clinical scenarios requiring diagnostic reasoning and management
decisions), and 25% analysis (integration of multiple findings, differential diagnosis, 'next best step' clinical reasoning). The correct
answer and a rationale with embedded clinical pearls and high-yield test-taking strategies are provided immediately beneath each
item to support self-assessment, remediation, and board-focused study.
Section 1: Cardiovascular Disorders (Q1-Q30)
Hypertension, Heart Failure, CAD, Dysrhythmias, & Lipid Management
Q1: A 58-year-old African American male presents for routine physical examination. His blood pressure today is
148/94 mmHg, confirmed on two readings. He has no history of cardiovascular disease or diabetes. According to
the 2017 ACC/AHA hypertension guideline, what is the appropriate classification and initial management?
A. Stage 1 hypertension; recommend lifestyle modification and recheck in 6 months
B. Stage 2 hypertension; recommend lifestyle modification PLUS antihypertensive medication with two agents
from different classes, with follow-up in 1 month [CORRECT]
C. Elevated blood pressure; recommend lifestyle modification only
D. Hypertensive crisis; refer immediately to the emergency department
Correct Answer: B
Rationale:
Per the 2017 ACC/AHA guideline, BP >=140/90 mmHg is Stage 2 hypertension, requiring both lifestyle modification and
pharmacologic therapy with TWO agents from different classes (typically thiazide + ACE/ARB/CCB for African American
patients). Clinical pearl: African American patients have a more robust BP response to thiazides and CCBs than to ACE inhibitors
monotherapy. Lifestyle modifications (DASH diet, sodium <1500 mg/day, exercise, weight loss, alcohol moderation) are
foundational at all stages.
Q2: A 62-year-old white female with stage 2 hypertension and a history of heart failure with reduced ejection
fraction (HFrEF, EF 30%) is started on antihypertensive therapy. Which of the following is the MOST
appropriate first-line antihypertensive agent?
A. Amlodipine 10 mg daily
B. Lisinopril 10 mg daily (ACE inhibitor with mortality benefit in HFrEF) [CORRECT]
C. Hydrochlorothiazide 25 mg daily
D. Clonidine 0.1 mg BID
Correct Answer: B
Rationale:
For patients with HFrEF, an ACE inhibitor (or ARB if ACE cough/angioedema) provides mortality benefit by reducing afterload
and counteracting maladaptive remodeling. ACE inhibitors are foundational in HFrEF alongside beta-blockers, MRAs, and SGLT2
Page 1 | Advanced Practice Nursing Board Review
,Sarah Michelle Live Review - FNP & AGNP Board Preparation 250 Questions - AGRADE Verified 2026/2027
inhibitors (GDMT). Clinical pearl: CCBs (non-dihydropyridines like diltiazem/verapamil) are CONTRAINDICATED in HFrEF
because they reduce contractility; amlodipine is generally neutral but not first-line. Clonidine is not first-line for chronic HTN.
Q3: A 76-year-old patient with hypertension, type 2 diabetes, and stage 3 CKD (eGFR 35 mL/min) is being
managed for elevated BP. The FNP recognizes that the preferred agent for renal protection in this patient is:
A. Hydrochlorothiazide 25 mg daily
B. Losartan 50 mg daily (ARB, with evidence of renal protection in CKD with albuminuria) [CORRECT]
C. Amlodipine 10 mg daily
D. Metoprolol succinate 50 mg daily
Correct Answer: B
Rationale:
ACE inhibitors and ARBs are preferred in patients with diabetes and CKD with albuminuria (UACR >=30 mg/g) because they
reduce intraglomerular pressure and slow progression of diabetic nephropathy. Monitor creatinine (may rise up to 30% acceptable)
and potassium. Clinical pearl: Thiazides lose efficacy at eGFR <30 (use loop diuretic); metoprolol does not provide renal protection.
Avoid aliskiren (renin inhibitor) combined with ACE/ARB in diabetics due to hyperkalemia and renal dysfunction risk.
Q4: A 28-year-old G2P1 at 24 weeks gestation presents with blood pressure 158/102 mmHg on two readings,
with 1+ proteinuria on dipstick. She has a frontal headache and blurred vision. The FNP recognizes the MOST
appropriate diagnosis and immediate action:
A. Chronic hypertension; continue prenatal care and recheck in 2 weeks
B. Preeclampsia with severe features (hypertension PLUS neurologic symptoms and proteinuria); requires
emergent obstetric evaluation, magnesium sulfate for seizure prophylaxis, and antihypertensive therapy (IV
labetalol or hydralazine) [CORRECT]
C. Gestational hypertension; outpatient monitoring only
D. Eclampsia; administer IV diazepam
Correct Answer: B
Rationale:
Preeclampsia with severe features is diagnosed with BP >=160 systolic or >=110 diastolic PLUS end-organ damage (neurologic
symptoms, proteinuria, elevated LFTs, thrombocytopenia, pulmonary edema, fetal growth restriction). Treatment: IV magnesium
sulfate for seizure prophylaxis, IV labetalol or hydralazine for BP control, and delivery if >=34 weeks. Clinical pearl: Eclampsia is
when seizures actually occur. Do NOT delay for further workup when severe features present.
Q5: A 65-year-old male with hypertension, type 2 diabetes, and Stage 3 CKD is on maximal doses of lisinopril
and amlodipine. His BP remains 152/94 mmHg. The FNP adds chlorthalidone 25 mg daily. Three weeks later,
the patient presents with severe muscle cramps and weakness. ECG shows peaked T waves and wide QRS. The
MOST likely diagnosis is:
A. Hypokalemia from thiazide diuretic
B. Hyperkalemia from RAAS blockade combined with CKD, exacerbated by additional renal hemodynamic
changes [CORRECT]
C. Hyponatremia
D. Hypomagnesemia
Correct Answer: B
Rationale:
Adding a thiazide to ACE inhibitor + CKD raises hyperkalemia risk (uncommon for thiazides alone, but the combination with ACE
+ CKD + diabetes is a high-risk scenario). ECG findings of peaked T waves and wide QRS are classic for hyperkalemia. Clinical
pearl: ALWAYS check BMP within 1-2 weeks of starting/adjusting ACE/ARB, especially in CKD and diabetes. Hypokalemia
would cause U waves, flat T waves, and ST depression. Treatment: calcium gluconate, insulin+glucose, albuterol, then definitive
Page 2 | Advanced Practice Nursing Board Review
,Sarah Michelle Live Review - FNP & AGNP Board Preparation 250 Questions - AGRADE Verified 2026/2027
removal (diuretics, GI resins, dialysis).
Q6: A 72-year-old female presents with BP 188/110 mmHg, severe headache, and confusion. Funduscopic exam
reveals papilledema. The FNP correctly identifies this as hypertensive emergency. The MOST appropriate
immediate intervention is:
A. Sublingual nifedipine 10 mg for rapid BP reduction
B. IV labetalol or nicardipine with continuous arterial line monitoring, reducing mean arterial pressure by no
more than 25% in the first hour [CORRECT]
C. Oral clonidine 0.2 mg, repeated as needed
D. Oral hydrochlorothiazide 25 mg
Correct Answer: B
Rationale:
Hypertensive emergency requires ICU admission and IV titratable antihypertensive (labetalol, nicardipine, clevidipine, esmolol).
Lower MAP by NO more than 25% in the first hour to prevent cerebral hypoperfusion (chronic HTN shifts cerebral autoregulation
curve). Clinical pearl: NEVER use sublingual nifedipine - rapid, unpredictable BP reduction can precipitate stroke, MI, or death.
Oral agents (clonidine, captopril) are for hypertensive urgency (no end-organ damage).
Q7: A 68-year-old male with HFrEF (EF 25%) presents with dyspnea on exertion, orthopnea, and 2+ bilateral
lower extremity edema. He is currently on furosemide 40 mg daily. Which FOUR medications constitute
Guideline-Directed Medical Therapy (GDMT) for HFrEF?
A. Furosemide, hydralazine, isosorbide dinitrate, and digoxin
B. ARNI (or ACE/ARB if intolerant), evidence-based beta-blocker (carvedilol/metoprolol succinate/bisoprolol),
mineralocorticoid receptor antagonist (spironolactone/ eplerenone), and SGLT2 inhibitor
(dapagliflozin/empagliflozin) [CORRECT]
C. ACE inhibitor, loop diuretic, digoxin, and statin
D. Beta-blocker, CCB, statin, and nitrate
Correct Answer: B
Rationale:
The FOUR pillars of GDMT for HFrEF are: (1) ARNI (sacubitril/valsartan) preferred over ACE/ARB; (2) evidence-based
beta-blocker (carvedilol, metoprolol succinate, bisoprolol - NOT metoprolol tartrate); (3) MRA (spironolactone or eplerenone); (4)
SGLT2 inhibitor (dapagliflozin or empagliflozin). Clinical pearl: ARNI cannot be given within 36 hours of ACE due to angioedema
risk. African American patients with NYHA III-IV HF benefit from hydralazine + isosorbide dinitrate addition. Diuretics are
symptom-relief only, not mortality-reducing.
Q8: A 70-year-old female is diagnosed with HFpEF (EF 55%) after an echocardiogram. She has hypertension,
type 2 diabetes, and chronic kidney disease. Which therapy has been shown to reduce HF hospitalizations in
HFpEF?
A. Carvedilol 12.5 mg BID
B. Empagliflozin 10 mg daily (SGLT2 inhibitor - approved for HFpEF based on EMPEROR-Preserved
trial) [CORRECT]
C. Lisinopril 20 mg daily
D. Spironolactone 25 mg daily
Correct Answer: B
Rationale:
SGLT2 inhibitors (empagliflozin, dapagliflozin) are the FIRST class to show benefit in HFpEF, reducing HF hospitalizations
(EMPEROR-Preserved, DELIVER trials). Diuretics provide symptom relief. Clinical pearl: Spironolactone (TOPCAT trial) showed
benefit in selected HFpEF patients but is more controversial. Beta-blockers, ACE/ARB, and ARNI do NOT improve outcomes in
Page 3 | Advanced Practice Nursing Board Review
, Sarah Michelle Live Review - FNP & AGNP Board Preparation 250 Questions - AGRADE Verified 2026/2027
HFpEF as they do in HFrEF. Management focuses on BP control, volume management, and treating comorbidities.
Q9: A 65-year-old male with HFrEF on GDMT (lisinopril, carvedilol, spironolactone, dapagliflozin) reports dry
cough for 3 months, worse at night. The FNP suspects ACE inhibitor-induced cough. The MOST appropriate
intervention is:
A. Discontinue carvedilol
B. Switch lisinopril to valsartan/sacubitril (ARNI), which has lower cough/angioedema risk and added mortality
benefit in HFrEF [CORRECT]
C. Addition of oral pseudoephedrine for symptomatic relief
D. Discontinue spironolactone
Correct Answer: B
Rationale:
ACE inhibitor cough occurs in 5-20% of patients due to accumulation of bradykinin (ACE normally degrades bradykinin). Switch to
ARB or ARNI - both avoid bradykinin pathway. ARNI (sacubitril/valsartan) is preferred in HFrEF due to mortality benefit
(PARADIGM-HF). Clinical pearl: ARNI must NOT be started within 36 hours of last ACE dose due to angioedema risk.
Spironolactone and carvedilol are not cough causes. Do NOT add decongestants.
Q10: A 70-year-old male on spironolactone 50 mg daily for HFrEF reports bilateral breast enlargement and
tenderness. Laboratory studies are otherwise normal. The MOST appropriate intervention is:
A. Discontinue spironolactone entirely
B. Switch to eplerenone 50 mg daily (selective MRA with lower anti-androgen effects, less
gynecomastia) [CORRECT]
C. Reduce the dose to 12.5 mg daily
D. Addition of tamoxifen
Correct Answer: B
Rationale:
Spironolactone binds androgen and progesterone receptors, causing gynecomastia (~10%), sexual dysfunction, and menstrual
irregularities. Eplerenone is a selective MRA with 100-fold lower affinity for androgen receptors, dramatically reducing
gynecomastia risk. Clinical pearl: Eplerenone has the same mortality benefit as spironolactone in HFrEF (EPHESUS,
EMPHASIS-HF). Don't discontinue MRA in HFrEF - it provides mortality benefit. Monitor K+ with both agents.
Q11: A 55-year-old male with type 2 diabetes, hypertension, and dyslipidemia presents for routine follow-up.
ASCVD 10-year risk is calculated at 12%. His lipid panel shows LDL 145 mg/dL, HDL 38 mg/dL, TG 200
mg/dL. The FNP correctly identifies the appropriate management per 2018 ACC/AHA cholesterol guidelines:
A. Continue lifestyle modifications; no statin indicated
B. Initiate moderate-intensity statin therapy (e.g., atorvastatin 10-20 mg or rosuvastatin 5-10 mg
daily) [CORRECT]
C. Initiate high-intensity statin therapy (e.g., rosuvastatin 20-40 mg daily)
D. Addition of ezetimibe first, then statin
Correct Answer: B
Rationale:
For primary prevention in adults 40-75 years with LDL 70-189 mg/dL and 10-year ASCVD risk >=7.5%, initiate moderate-intensity
statin. Diabetes is an automatic statin indication; moderate-intensity for diabetics 40-75 years at <7.5% risk, high-intensity at
>=7.5%. Clinical pearl: Discuss risk-enhancing factors (family history, CKD, metabolic syndrome, triglycerides >175, hs-CRP >2,
LP(a) >125 nmol/L, ABI <0.9) for borderline risk (5-7.5%) decisions. Lifestyle first but never as monotherapy when statin indicated.
Page 4 | Advanced Practice Nursing Board Review
